Pelvic inflammatory disease: Difference between revisions
 
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==Background==
==Background==
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]]
*Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
*Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
**Salpingitis, endometritis, myo/parametritis, oophoritis
**Salpingitis, endometritis, myo/parametritis, and oophoritis
***Perihepatitis ([[Fitz-Hugh-Curtis]]) is caused by lymphatic spread
**Perihepatitis ([[Fitz-Hugh-Curtis]]) is caused by lymphatic spread
***Tubo-ovarain abscess is caused by direct extension
**[[Tubo-ovarian abscess]] is caused by direct extension
*Most common serious infection in women aged 16 to 25 years
*It is the most common serious infection in women aged 16 to 25 years and begins as [[cervicitis]] (commonly due to [[GC]] or [[chlamydia]]) that may progress to polymicrobial infection.
**Most common cause of death is rupture of a tubo-ovarian abscess
*Begins as cervicitis w/ [[GC]] or [[chlamydia]] that may progress to polymicrobial infection  
**Initial lower tract infection may be asymptomatic
**Initial lower tract infection may be asymptomatic
**Most common cause of death is rupture of a [[tubo-ovarian abscess]]
**Can be caused by organisms such as [[M. genitalium]] which is very difficult to isolate and will not be picked up on routine testing
*Bilateral tubal ligation does not confer protection against risk<ref>Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017. https://emedicine.medscape.com/article/256448-clinical#b1.</ref>


==Diagnosis==
===Risk factors<ref>Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.</ref>===
*Age < 25
*Age at first sexual intercourse < 20
*Non-white ethnicity
*Nulliparous
*History of transmitted diseases, especially chlamydia
*[[IUD]] within 21 days after insertion<ref>https://www.cdc.gov/std/tg2015/pid.htm</ref>
 
==Clinical Features==
===History===
===History===
#[[Pelvic Pain]] (90%)
*[[Pelvic Pain]] (90%)
#Vaginal discharge (75%)
*[[Vaginal discharge]] (75%)
#Vaginal and postcoital bleeding (>33%)
*[[vaginal bleeding|Vaginal and postcoital bleeding]] (>33%)
#Dysuria, [[fever]], malaise, [[N/V]]
*[[Dysuria]], [[fever]], malaise, [[nausea and vomiting]]


===Physical Exam===
===Physical Exam===
#CMT
*Cervical motion tenderness
#Adnexal tenderness
*Adnexal tenderness (Most sensitive finding - Sn ~95%)
#*Most sensitive finding (Sn ~95%)
*Mucopurulent cervicitis
#Mucopurulent cervicitis
**Absence should prompt consideration of another diagnosis
#*Absence should raise consideration of another dx
*[[RUQ Pain]]
#[[RUQ Pain]]
**May indicate perihepatic inflammation (particularly if [[jaundice]] also present)
#*May indicate perihepatic inflammation (particularly w/ [[jaundice]])
 
===CDC Treatment Criteria===
#Woman at risk for [[STIs]]
#Pelvic or lower abdominal pain
#No cause for the illness other than PID can be identified
#At least one of the following on pelvic exam:
##CMT
##Uterine tenderness
##Adnexal tenderness.
#Additional criteria that make the dx more likely:
##Oral temperature >101° F (>38.3° C)
##Abnormal cervical or vaginal mucopurulent discharge
##Pesence of abundant numbers of WBC on saline microscopy of vaginal fluid
##Elevated ESR
##Elevated CRP
##Laboratory documentation of cervical infection with [[GC]] or [[chlamydia]]
 
==Work-Up==
#Urine pregnancy
#Wet mount
#Endocervical swab (for [[GC]], [[Chlamydia]])
#CBC
#ESR/CRP
#Urine culture, analysis (to excl [[UTI]])
 
===Imaging===
#Pelvic U/S
##Ultrasound sensitivity may be as low as 56% and specificity of 85% <ref>Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med.
2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506 </ref>
#CT


==Differential Diagnosis==
==Differential Diagnosis==
{{Pelvic pain DDX}}
{{Pelvic pain DDX}}


== Treatment ==
==Evaluation==
;Tx all partners who had sex w/ pt during previous 60d prior to onset of sx
[[File:PMC3369119 13244 2012 157 Fig8 HTML.png|thumb|PID with pyosalpinx on transvaginal ultrasound: bilateral adenexal cysts consistent with pyosalpinges (white arrows).]]
[[File:PMC3369119 13244 2012 157 Fig9 HTML.png|thumb|PID on CT with bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation and an associated ileus.]]
===Workup===
*Urine pregnancy
*Wet mount
*Endocervical swab (for [[GC]], [[Chlamydia]])
*CBC
*ESR/CRP
*Urine culture, analysis (to exclude [[UTI]])
*[[Pelvic ultrasound]]
**Ultrasound sensitivity may be as low as 56% and specificity of 85% <ref>Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med.
2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506 </ref>
*Consider CT to rule-out other causes of lower [[abdominal pain|abdominal]]/[[pelvic pain]]
**''Multiple intra-abdominal processes can cause cervical motion tenderness, including [[appendicitis]]''


=== Outpatient Options ===
===CDC Empiric Diagnosis Criteria<ref>http://www.cdc.gov/std/tg2015/pid.htm </ref>===
#[[Ceftriaxone]] 250mg IM x1 + [[doxycycline]] 100mg PO BID x14d +/- [[metronidazole]] 500mg PO BID x14d <ref>Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37</ref>
''Due to inability to test for all causative pathogens and the potential for serious complications such as infertility, the CDC has made this a purposefully vague condition with a low threshold for empiric treatment''
#*[[Metronidazole]] based upon assessment of risk for [[anaerobes]]; consider in:
*Woman at risk for [[STIs]]
#**Pelvic abscess
*Pelvic or lower abdominal pain
#**Proven or suspected infection w/ [[Trichomonas]] or [[Bacterial Vaginosis]]
*No cause for the illness other than PID can be identified
#**History of gynecological instrumentation in the preceding 2-3wks
*At least one of the following on pelvic exam:
#OR, [[Cefoxitin]] 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose<ref>CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm</ref> + [[Doxycycline]] 100 mg PO BID x 14 days +/- [[flagyl]] based on above criteria
**CMT
**Uterine tenderness
**Adnexal tenderness.
*Additional criteria that make the diagnosis more likely:
**Oral temperature >101° F (>38.3° C)
**Abnormal cervical or vaginal mucopurulent discharge
**Presence of abundant numbers of WBC on saline microscopy of vaginal fluid
**Elevated ESR
**Elevated CRP
**Laboratory documentation of cervical infection with [[GC]] or [[chlamydia]]


===Alternative Outpatient Options===
==Management==
#[[Ceftriaxone]] 250mg IM x1 + 1 g of [[azithromycin]] per week, x 2 weeks<ref name="Savaris">Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60</ref> +/- flagyl based on above criteria
{{PID antibiotics}}
#*Great cure rates in the [[azithromycin]] group (98.2% vs 87.5%)<ref name="Savaris"></ref>


=== Inpatient ===
===[[IUD]]===
#[[Cefoxitin]] 2gm IV q6hr OR [[cefotetan]] 2gm IV q12hr) + [[doxycycline]] PO or IV 100 mg q12hr OR
*No change in treatment if IUD in place (may treat without removal)
#[[Clindamycin]] 900mg IV q8h + [[gentamicin]] 2mg/kg QD OR
#[[Ampicillin-sulbactam]] 3gm IV q6hr + [[doxycycline]] 100mg IV/PO q12hr


==Disposition==
==Disposition==
Admit:
===Admit===
*[[Tubo-ovarian abscess]]
*[[Tubo-ovarian abscess]]
**Hemodynamically unstable, TOA > 9 cm, postmenopausal, outpatient failure --> admit for surgical or VIR drainage
*[[Fitz-Hugh-Curtis]]
*[[Fitz-Hugh-Curtis]]
*[[Pregnancy]]
*[[Pregnancy]]
*[[Sepsis]]/[[peritonitis]]
*[[Sepsis]]/[[Peritonitis]]
*Unable to tolerate PO
*Unable to tolerate PO
*Failed outpt Rx
*Failed outpatient treatment
*[[HIV]]+
 
Discharge:
===Discharge===
*72hr f/u
*72hr follow up
*Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated
*Instruct patient to abstain from sex or adhere strictly to condom use until partner treatment and symptoms have abated
*HIV+ is not an automatic criteria for admission, consider overall clinical impression


==Complications==
==Complications==
#[[Tubo-Ovarian Abscess]]
*[[Tubo-ovarian abscess]]
#[[Fitz-Hugh-Curtis]]
*[[Fitz-Hugh-Curtis]]
##Perihepatic inflammation seen only on CT, not US; LFTs are normal
**Perihepatic inflammation seen only on CT, not US; LFTs are normal
##Responds to standard abx regimen
**Responds to standard antibiotic regimen
#Infertility
*Infertility
#[[Ectopic Pregnancy]]
*[[Ectopic pregnancy]]
#Chronic pelvic pain
*Chronic [[Pelvic pain|pelvic pain]]


==See Also==
==See Also==
*[[Sexually Transmitted Diseases (STD)]]
*[[Sexually Transmitted Diseases (STD)]]
*[[Pelvic Pain]]
*[[Pelvic pain]]


== Source ==
==References==
<references/>
<references/>
[[Category:ID]] [[Category:OB/GYN]]
 
[[Category:ID]]  
[[Category:OBGYN]]

Latest revision as of 17:31, 27 May 2021

Background

Pelvic anatomy.
  • Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
  • It is the most common serious infection in women aged 16 to 25 years and begins as cervicitis (commonly due to GC or chlamydia) that may progress to polymicrobial infection.
    • Initial lower tract infection may be asymptomatic
    • Most common cause of death is rupture of a tubo-ovarian abscess
    • Can be caused by organisms such as M. genitalium which is very difficult to isolate and will not be picked up on routine testing
  • Bilateral tubal ligation does not confer protection against risk[1]

Risk factors[2]

  • Age < 25
  • Age at first sexual intercourse < 20
  • Non-white ethnicity
  • Nulliparous
  • History of transmitted diseases, especially chlamydia
  • IUD within 21 days after insertion[3]

Clinical Features

History

Physical Exam

  • Cervical motion tenderness
  • Adnexal tenderness (Most sensitive finding - Sn ~95%)
  • Mucopurulent cervicitis
    • Absence should prompt consideration of another diagnosis
  • RUQ Pain
    • May indicate perihepatic inflammation (particularly if jaundice also present)

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

PID with pyosalpinx on transvaginal ultrasound: bilateral adenexal cysts consistent with pyosalpinges (white arrows).
PID on CT with bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation and an associated ileus.

Workup

  • Urine pregnancy
  • Wet mount
  • Endocervical swab (for GC, Chlamydia)
  • CBC
  • ESR/CRP
  • Urine culture, analysis (to exclude UTI)
  • Pelvic ultrasound
    • Ultrasound sensitivity may be as low as 56% and specificity of 85% [5]
  • Consider CT to rule-out other causes of lower abdominal/pelvic pain
    • Multiple intra-abdominal processes can cause cervical motion tenderness, including appendicitis

CDC Empiric Diagnosis Criteria[6]

Due to inability to test for all causative pathogens and the potential for serious complications such as infertility, the CDC has made this a purposefully vague condition with a low threshold for empiric treatment

  • Woman at risk for STIs
  • Pelvic or lower abdominal pain
  • No cause for the illness other than PID can be identified
  • At least one of the following on pelvic exam:
    • CMT
    • Uterine tenderness
    • Adnexal tenderness.
  • Additional criteria that make the diagnosis more likely:
    • Oral temperature >101° F (>38.3° C)
    • Abnormal cervical or vaginal mucopurulent discharge
    • Presence of abundant numbers of WBC on saline microscopy of vaginal fluid
    • Elevated ESR
    • Elevated CRP
    • Laboratory documentation of cervical infection with GC or chlamydia

Management

Antibiotics

  • No sexual activity for 2 weeks;
  • Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

Inpatient Antibiotic Options

IUD

  • No change in treatment if IUD in place (may treat without removal)

Disposition

Admit

Discharge

  • 72hr follow up
  • Instruct patient to abstain from sex or adhere strictly to condom use until partner treatment and symptoms have abated
  • HIV+ is not an automatic criteria for admission, consider overall clinical impression

Complications

See Also

References

  1. ↑ Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017. https://emedicine.medscape.com/article/256448-clinical#b1.
  2. ↑ Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.
  3. ↑ https://www.cdc.gov/std/tg2015/pid.htm
  4. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  5. ↑ Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
  6. ↑ http://www.cdc.gov/std/tg2015/pid.htm
  7. ↑ Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
  8. ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  9. ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  10. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  11. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  12. ↑ Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
  13. ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  14. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
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